THE NATION

Angioplasty should be used more, doctors say

Improvements in angioplasty in the last few years have made the procedure for unblocking coronary arteries much safer, allowing cardiologists to perform procedures they were reluctant to do in the past.

The procedures include performing angioplasty after clot-busting drugs have been given and using it in hospitals that don't have a heart surgery team available for emergencies, researchers said during a weekend cardiology meeting in Chicago.

The net effect is that angioplasty, which is generally considered to be much more effective than drugs for treating heart attacks, should be available to many more patients, researchers said.

The findings "really could change practice and open up opportunities for patients to get more optimal treatment," said Dr. Bonnie Weiner of St. Vincent Hospital in Worcester, Mass., president of the Society for Cardiovascular Angiography and Interventions.

More than 75% of hospitals in the U.S. do not routinely perform angioplasty, also known as percutaneous coronary intervention -- most because they do not have heart surgeons on staff to make repairs if the procedure punctures an artery or causes some other damage.

When patients arrive at such a hospital after a heart attack, the only choice is to administer clot-busting drugs within the 90-minute "golden window" in which treatment is most effective.

Once such therapy has been administered, cardiologists have been reluctant to transfer patients to another hospital to undergo angioplasty out of fear that the procedure would cause excess bleeding and endanger their lives.

The fear now appears to be groundless and counterproductive, Dr. Warren J. Cantor of the Southlake Regional Health Centre in Newmarket, Ontario, Canada, reported Sunday at a meeting of the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions.

Cantor reported on 1,010 patients who suffered a moderate or severe heart attack and sought treatment at hospitals that could not perform angioplasty.

All were given the second-generation clot-busting drug tenecteplase, which has fewer problems than older drugs. Half were then transferred to another hospital to receive angioplasty within six hours; the other half were given conventional medical treatment.

Cantor said the results were dramatic.

Overall, 16.6% of patients who received only drugs suffered another heart attack, severe chest pains or died in the 30 days after the procedure, compared with 10.6% of those who received prompt angioplasty. That was a 46% reduction.

The incidence of recurrent heart attack was 6% in the drug group, compared with 3.3% in the angioplasty group. Recurrent chest pain occurred in 2.2% of drug patients, compared with 0.2% of angioplasty patients.

There was no excess bleeding in the patients who underwent angioplasty.

"What it says is that when patients receive [clot-busting drugs], there is no value in remaining at that hospital," Cantor said. "The best strategy is to transfer them to an angioplasty center to undergo the procedure within six hours."

Added Dr. Steven Bailey of the University of Texas Health Sciences Center at San Antonio: "Such a large benefit to the patient . . . is reassuring that this should be a process that we begin to adopt in order to care for the majority of patients who have heart attacks."

Nonemergency angioplasty has been more controversial because medical guidelines call for it to be performed only in a hospital where a backup surgical team is available in case problems arise. Several states ban the practice except in emergencies.

Such prohibitions were imposed because years ago emergency surgery was required for about 8% of patients who underwent angioplasty, said Dr. Michael Kutcher of Wake Forest University.

Today that figure has shrunk to 0.2% to 0.4%.

As a result, a growing number of small hospitals without surgical backup have been attempting the procedure -- which can earn them as much as $15,000 per incident -- and the evidence suggests that the practice is safe, Kutcher told the meeting Saturday.

Hospitals also argue that performing the elective surgeries helps staffers to maintain proficiency.

Using a national patient registry maintained by the American College of Cardiology, Kutcher and his colleagues compared results from 9,029 patients who had angioplasty at 61 small hospitals with those from 299,132 patients at 404 hospitals with backup teams between January 2004 and April 2006.

They found no significant difference in deaths between the two types of facilities, once they factored in the age of the patients and the severity of the illness.

Success rates and the number of complications were also similar, Kutcher said, suggesting that the procedure can be done safely at smaller hospitals.

The findings "could have a huge impact in this country," particularly in rural areas where hospitals that perform angioplasty can be hours away by car, said Dr. W. Douglas Weaver of the Henry Ford Hospital in Detroit, president-elect of the American College of Cardiology.

But Kutcher and others cautioned that the findings should not be used to support the "wild development" of new stand-alone programs for angioplasty.

It is crucial, Weiner said, that hospitals perform a minimum number of procedures to maintain their efficacy in surgery, and that they compare their results to national norms to ensure their results are acceptable.